We are approaching the tenth anniversary of the attacks of September 11, 2001. It is one of the most traumatic incidents in our nation's history. The anniversary is a reminder of the physical and emotional trauma experienced by thousands of people. Even a decade later, emotional trauma continues for many of the men and women in the military who are fighting in conflicts that resulted from the 9/11 attacks. In the wake of a trauma, the first impulse is usually to rush to the scene with a zealous willingness to help. In times of large-scale crisis, there is often a push to provide a large force of mental health clinicians to help everyone affected. But a more cautious approach to providing help may be the better option. So what does the research suggest is most helpful in the wake of tragedies? Research suggests that help should be individualized. The one-size-fits-all approach does not take into account each person's unique responses to trauma and capacity for resilience. Some people may want to talk about the experience. But for others, talking may just reinforce and intensify memories that are better forgotten. For example, repeatedly broadcasting the images of collapsing towers on TV may have intensified mental distress especially for people who lived in New York City, closest to the disaster. An example of a type of treatment that should probably be avoided is an approach called "critical incident stress debriefing." This technique became popular in the 1980s for emergency service workers, such as firefighters and police officers. It involves reviewing traumatic experiences in a group setting. By the end of the 1990s, researchers found that a single critical incident stress debriefing session did not reduce the risk of developing post-traumatic stress disorder (PTSD). In fact, it appeared to increase the incidence of psychological distress in some cases. A group of researchers thought more than one session might be the key. So they looked for randomized controlled trials using treatments that:
The studies involved people who had experienced a frightening loss of life, a life-threatening injury or a grave threat. Eight studies met the review criteria. They included a wide range of established techniques: cognitive behavior therapy, stress management, relaxation, eye movement desensitization and reprocessing, teaching of coping skills or general psychological information. These studies were conducted in various countries. They involved a range of traumatic events, such as physical assault, armed robbery, traumatic births and traffic accidents. Unfortunately there was no evidence that any of the treatments were effective in preventing symptoms of PTSD, anxiety or depression. And, as with debriefing, some people may have gotten worse. You'd expect that providing group support and reassurance, and teaching coping skills and relaxation techniques would be helpful to all trauma victims. But research has found that the simple act of attending a group session may cause some people to go over and over the traumatic events when they would not otherwise do so. Just talking to others in the group about the events can increase PTSD symptoms in some people. Bottom line: Some people exposed to traumatic events do not benefit from psychological help. More research is needed to help clinicians decide what intervention is best for each individual and — perhaps more important — when to intervene. The Need for Help Doesn't Go Away During a tragedy, people want to come together and help. But eventually the crisis passes and people go back to their regular lives. They have to. This is when it often becomes more difficult to get the kind of formal or informal help a person may need to adjust to a new reality. The needs are often great and resources are limited. Given what we know about large-scale attempts to provide mental health services, perhaps more of those resources should be set aside for later. It may sound less dramatic, but it may be more beneficial. Michael Craig Miller, M.D., is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.
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